The effects of dance interventions on physical function and quality of life among middle-aged and older adults: A systematic review

Background Fundamental physical functions such as postural control and balance are vital in preserving everyday life, affecting an individual’s quality of life. Dance is a physical activity that offers health advantages across various life stages. Nevertheless, the effects of dance interventions on physical function, postural control, and quality of life among older adults have remained underexplored. The review aimed to examine the strength of evidence for dance interventions on physical function and quality of life among middle-aged and older adults. Methods A systematic review was conducted across four databases (PubMed, Cochrane Library, Web of Science, and Medline), focusing on studies involving more than four weeks of dance interventions. MeSH terms [dance or dance intervention or dance rehabilitation or dance movement] and [motor function or functional capacity or postural control or functional mobility or mobility or postural balance or balance or flexibility or gait] and [well-being or quality of life or life satisfaction] were utilized in the search. This review was registered in the PROSPERO database (CRD42023422857). Included studies were assessed using the Cochrane Risk of Bias. Results The search revealed 885 studies, and 16 met the inclusion criteria. The effects of various dance genres on physical functions and quality of life were compared. Most studies showed that dance intervention improved physical function, balance, postural control and quality of life. Dance intervention showed a high level of adherence compared to physiotherapy, self-care, conventional therapy, and aerobic and resistance exercise. Conclusion In terms of improving physical function and quality of life, structured dance is a safe and relatively effective alternative to exercise. Note the effect of movement selection and intensity in the dance interventions. Dance with music may increase participants’ interest, encouraging more physical activity among middle-aged and older adults.


Introduction
With the growing ageing population globally, the health and well-being of older adults have become increasingly important topics of concern [1].This demographic shift has prompted a growing need to focus on the unique healthcare challenges and requirements faced by older adults [2].As individuals age, potential health conditions become more prevalent.Aging is often accompanied by a decline in sensory, motor [3], and cognitive functions [4], which increases the vulnerability of older adults towards adverse health risks.
Age-related fundamental physical functions, such as postural control and balance [5], are crucial for preserving the well-being of middle-aged and older adults.Effective posture control ensures safe and stable movement, contributing to the overall physical function [6].It has been observed that middle-aged and older adults often exhibit a reduced capability for postural adjustments required to regain stability [7].Adequate posture control holds utmost significance in averting falls and injuries while also facilitating the execution of daily tasks, which contributes to enhanced quality of life (QoL) [8].As a result, alternative and enjoyable avenues of physical activity to foster improved health results and elevate one's holistic sense of wellbeing have gained growing attention.
Dance has received much attention as a potential intervention as it is a complex activity that combines physical exercise with cognitive, social, and artistic stimulation [9].Dances are inherently multimodal, involving physical activity or exercise, learning, attention, memory, emotion, rhythmic motor coordination, balance, gait, visuospatial ability, acoustic stimulation, imagination, improvisation, and social interaction [10].Available studies [10][11][12][13] explore how various types of dance affect individual health and cognition, but there have been limited research reviews on the effects of dance on physical function and QoL.
The current review aimed to evaluate the influence of dance interventions on physical function and QoL among middle-aged and older adults.The purpose was to discern potential variations in the effectiveness of dance interventions regarding the distinct health states of older adults and the different effects involving dance and other types of intervention (or no intervention).The questions of whether dance can emerge as a feasible and efficient intervention and its potential integration into diverse healthcare initiatives, rehabilitation centers, and community-based projects were considered.

Methods
This review was registered in the PROSPERO database (CRD42023422857) and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [14].

Search strategy
A systematic advanced search on PubMed, Cochrane Library, Web of Science, and Medline databases was conducted to identify full-text publications of eligible studies.The literature search was completed from inception until 1st May 2023.The search was limited to human studies and publications in English and Chinese based on the following medical subject headings (MeSH) search terms: [dance or dance intervention or dance rehabilitation or dance movement] and [motor function or functional capacity or postural control or functional mobility or mobility or postural balance or balance or flexibility or gait] and [well-being or quality of life or life satisfaction].Besides that, reference lists of identified and included studies were manually searched for any studies not found in the database search.Inclusion and exclusion criteria for the review were determined a priori.

Inclusion criteria
The inclusion criteria were randomized controlled trials and original studies with dance interventions with physical function and well-being outcomes such as posture control, functional mobility, balance, and quality of life (or life satisfaction); middle-aged and older adults (>40 years) participants with no restrictions on health status.; accessible full text in either Chinese or English; intervention duration had to be a minimum of four weeks.Dance in this study refers to the movement of the body in a rhythmic manner [12].

Exclusion criteria
Conference proceedings or abstracts, editorials, commentaries, opinion-based papers review articles (systematic and narrative), case series, and case studies, studies with no control group, interventions that combined dance with other movement, and interventions that used dance primarily as a therapy for mental health issues were excluded.

Data extraction
After the search, article titles and abstracts were initially screened against the inclusion/exclusion criteria based on population, intervention, control/comparator, and outcome (PICO, Table 1) by J.L. and N.A.A.R.The same authors independently assessed the quality of the included studies, whereby S.S. resolved any discrepancies between the reviewers.Then, J.L. extracted the following data from each included study: name of the author(s), year of publication, sample size, attrition (calculated as the proportion of dropouts from the initial sample size), participants' characteristics, mean age, details on the intervention program, and outcomes measured.

Study selection
The initial search resulted in 885 articles (Fig 1).After duplicates (279) were removed, there were 606 articles.Following the title and abstract review, 350 articles were further eliminated.Finally, 16 studies were deemed eligible to be included in this review.
• Flexibility: The chair sit-and-reach test.
• Motor agility/ dynamic balance: The 8-ft up-and-go test.
• Life satisfaction: The Satisfaction with Life scale.

Physical function outcomes
In 16 studies, physical function outcomes were compared in nine studies [16,17,[21][22][23][25][26][27][28] between dance intervention and control group without physical activity (Table 4).Additionally, seven studies [11, 12, 18-20, 24, 29] compared physical function between the dance intervention group and the control group that incorporated physical activity (Table 5).12 out of 16 studies highlighted slight to moderate improvements in physical function outcomes resulting from dance interventions.These enhancements were particularly noticeable in motor skills, such as increased gait speed and improved postural control encompassing balance, stability, gait, stride length, and sway.From the data extracted from these studies, it was observed that Turkish folk dance [25], belly dance [16], Agilando dance [27], creative dance [17], Greek traditional dance [21], ballroom dance [26] and Zumba [28] significantly improved physical function.In contrast, the physical function of the control group without physical activity showed no significant difference or decrease.Rocha et al. [11] compared Argentine tango against mixed dance genre intervention.Both interventions reported improvements in mobility, balance, and motor disability and the improved freezing of gait and QoL.Greek dance [19] and aerobic and resistance exercise exhibited the same benefits on physical performance and QoL, with no significant differences in the control group without intervention.An Indian dance intervention [12] reported more significant improvements in balance, risk of falls, physical function, and QoL than conventional therapy.Flamenco and Sevillanas [18] significantly contributed to better balance performance and physical activity levels than the other group that received self-care advice and physical activity.In a 2013 Irish dance study [20], Irish dance showed better outcomes in the Unified Parkinson's Disease Rating Scale (UPDRS) motor section, Time Up and Go (TUG), and Freezing of Gait (FOG) compared to physiotherapy.These findings suggest that Irish dance improves movement disorders, gait, and balance.
It is worth noting that four studies showed opposite results.An analysis of the dance versus the control group [22] reported that the gait speed of the dance group increased (+0.03 m/s) while that of the control group decreased (−0.03 m/s), although the difference was not statistically significant.The results of the postural sway control group decreased by 9mm, but those of the dance group showed an increase of 3 mm postural sway.Folk-dance style showed worse score on the short physical performance battery test and five chair rises.In another study on dance and usual care for Parkinson's disease [23], the dance group reported a minimal increase in UPDRS III scores, while the control group's scores worsened.However, endurance decreased in both groups, with a more significant decline in the control group.One study [29] comparing home exercise and dance intervention found that motor and gait outcomes showed no significant improvement except for dynamic balance in the dance group.Another study [24] with a four-arm intervention (tango, foxtrot/waltz, taichi and no intervention) reported no significant differences in physical function outcomes.

Quality of life outcomes
The results for quality of life (QoL) have been summarized in Tables 6 and 7.Ten studies revealed positive outcomes for QoL and life satisfaction following dance intervention.Among them, seven studies [16,17,21,[25][26][27][28] showed a significant improvement in the QoL for the dance group, while the control group's results tended to remain stable or worsen.A study [17] focusing on life satisfaction demonstrated a significant improvement at 12 and 24 weeks, with no notable change in the control group.Two studies indicated a similar significant improvement in the QoL for dance groups compared to those undergoing aerobic and resistance exercises [19] and conventional therapy [12].Regarding intergroup QoL, no significant differences were observed.Six studies have reported different results.One study (dance vs. regular day life) [22] showed that both groups' QoL scores decreased.Another study [23] showed a slight increase in QoL for the dance group but improved non-significantly in dance and the usual care group.Three studies [11,18,29] showed no significant differences between pre and post-intervention in both groups.A four-arm study (including tango, foxtrot/waltz, tai chi and no intervention) [24] demonstrated significant improvements in mobility (p = 0.03), social support (p = 0.05), and PDQ-39 Summary Index in health-related quality of life (HRQoL) for the Tango group, and no significant changes in HRQoL were noted in the waltz/foxtrot, tai chi or no intervention groups.

Discussion
The current review focused on the effects of dance interventions on physical function and QoL among middle-aged and older adults.A total of 16 studies were identified; nine studies compared dance interventions and control groups without any intervention, while seven other studies compared dance interventions to different types of physical activity.The review indicates that dance has the potential to yield notably positive effects on physical function, particularly on postural control, balance, motor skills, and QoL.Regarding physical function, twelve studies reported the favorable exercise benefits of dance interventions for postural control, gait stability, and balance.Four studies found no significant differences before and after the sessions.Ten studies found substantial improvements in QoL following the dance interventions.Still, four other studies found no significant differences, and two other studies observed a decline in the quality-of-life outcomes.

Effects of dance interventions on physical function and quality of life among middle-aged and older adults
Enhancing functional capabilities is paramount for middle-aged and older adults, particularly regarding their capacity to remain independent in daily activities.The included studies reported improved physical function and QoL among healthy middle-aged and older adult groups in Turkish folk dance [25], Agilando dance [27], and Indian folk dance [12].Significant benefits were seen in motor skills (walking speed, gait), postural control and balance.Indian folk dance as an intervention significantly improved balance, fall risk, functional ability, and QoL, with similar or even better results than traditional therapeutic interventions [12,30].Indian dance repeatedly stimulates the somatosensory system and motor senses through dynamic changes in stretching postures, rotational movements, and basic footwork [30].Unlike conventional therapy, this complex combination of movements can significantly enhance balance function [12].Good balance is crucial for maintaining postural equilibrium, reducing the risk of falls and facilitating older adults' day-to-day activities [31].Balance impairments associated with mobility and daily activities can significantly contribute to a decline in the QoL for middle-aged and older adults [32], thereby diminishing their sense of well-being.Studies included in the analysis explored two dance interventions for Parkinson's disease: Irish dance [20,23] and Argentine tango [11].Dance interventions might have significant efficacy in assisting individuals with early-to mid-stage Parkinson's disease.Volpe et al. [20] noted that dance intervention and physiotherapy positively improved physical function and QoL.The Irish dance group exhibited superior outcomes in freezing of gait, balance, and movement impairments compared to the physiotherapy group.Additionally, an interaction effect between intervention and time was observed in the dance group.No significant differences were found in the QoL between the two groups.In Shanahan et al. [23] study of Irish dance, the dance group showed improvements in motor function, QoL, and balance compared to the control group without and intervention.Despite the reduction in endurance observed in both groups, the decrease in the dance group was less than half of that in the control group, suggesting a protective effect in the dance group [23].Better movement and balance were observed in the Argentine tango group, and gait freezing improved with the mixed-type dance.However, the Argentine tango and mixed dance groups had no significant differences in QoL [11].Argentine tango and mixed dance steps are rhythm-oriented changes that move to the rhythm of the music, which provides alternative ways to adjust movement timing, improve physical performance and learn.
It is important to note the varying results of these studies.Hackney and Earhart [24] examined the QoL in patients with Parkinson's disease who received waltz/foxtrot, Argentine tango, tai chi, and a control intervention.They reported significant improvements in overall healthrelated quality of life (HRQoL), specifically its relationship to mobility and support.At the same time, there were no significant changes in the Unified Parkinson's Disease Rating Scale III in all groups.Compared to self-exercise at home, significant improvements in dynamic balance and gait for the Argentine Tango group were noted.Still, there were no significant differences in quality-of-life outcomes between both groups [29].Argentine tango may not directly address movement in Parkinson's disease symptoms, but it has shown promising results in improving balance.Argentine tango requires specific motor skills, including repeated start and stop motions, diverse movement speeds, rhythmic variation, and spontaneous multidirectional perturbations [33].People with Parkinson's disease may benefit from dancing classes that incorporate elements such as rhythmical music, large-amplitude fast movements, dancing with partners and step routines.It is crucial to encourage people with a chronic and progressive condition such as Parkinson's disease to be physically active [34].Participants consistently expressed that dance interventions were motivating and enjoyable exercises [23], further driving their interest in continued engagement.Nonetheless, a correlation has been identified between low-dose dance intervention and group-related advantages [11], with the effect size associated with the intervention duration.The acquisition of dance movements follows a progression from simple to complex and slow to fast, enabling participants to practice the movement sequence systematically.Prolonged intervention periods may promote automaticity in movement and intensify the overall impact [35].Short-term intervention might not yield substantial improvements in physical function and QoL.Also, we highlighted the benefits of dance intervention, including Flamenco Spanish dance [18] and Zumba dance [28], on postmenopausal women.These positive effects include mobility, balance, physical activity, and fitness improvements.The dance motions, such as jumping, spinning, and quick movement [36], induce neuromuscular adaptations [37], leading to increased strength of the lower limb and postural balance.The muscle strength gained from Zumba training may positively impact women's physical function [38].Indeed, among postmenopausal women, consistent engagement in exercise has been shown to contribute to the prevention of bone loss and improvement of balance and strength [39].The study noted more pronounced improvements in the QoL of postmenopausal individuals in the Zumba dance group than those in the Flamenco Spanish dance group.Lelard et al. [40] reported a correlation between positive emotions and improved balance performance.Positive emotions may arise from the diverse range of Latin dance choreographies and energetic music used in Zumba class [41].The previous study observed an equally improved QoL through Zumba training among older women [42].
The review noted favorable outcomes of dance interventions on fatigue and pain.It is known that pain, fatigue and physical activity are tightly intertwined [43].76% of fibromyalgia patients felt light activity worsened their pain and fatigue [42].In the study, the dance group noted heightened pain and fatigue levels during the initial four-week period, which gradually diminished as time progressed and felt relaxed in daily life [16].Fatigue significantly correlates with patients' well-being, physical function, and QoL [44].Based on the observations, fibromyalgia patients reduced pain from belly dance and improved performance in daily activities, which lasted for sixteen weeks post-intervention.Concurrently, significant enhancements were observed in the pain, emotional facets, and mental well-being dimensions of the Short Form-36, which had a positive effect lasting 32 weeks [16].Fatigue is one of the most enduring long-term symptoms among cancer survivors that significantly disrupts their everyday functioning [45].Among cancer survivors, ballroom dance has reduced fatigue and enhanced QoL, particularly physical activity and vitality.This results in improved relationships with partners and adaptability to return to normal life [26].Dance can improve flexibility and muscle strength, thereby reducing feelings of pain and fatigue.A study with chronic heart failure also confirmed beneficial results in physical function with reduced fatigue when Greek traditional dance was included in a rehabilitation program [19].
Previous studies [46,47] have consistently shown that patients with schizophrenia experience a reduced QoL, possibly due to the lasting effects of stigma and discrimination.When Greek traditional dance was added to rehabilitation programs for patients with schizophrenia, significant improvements in the functional capacity and QoL [21].Since traditional Greek dance action in a sequence and coordinated to music can improve balance, the lack of improvement in walking ability may be due to insufficient intensity.Regardless of the health status of older adults, creative dance improved aerobic endurance, flexibility, and life satisfaction, with better outcomes for longer dance interventions [29].However, a social dance program for seniors living independently in retirement villages did not exhibit better effects in terms of falls and QoL [26].This result may be due to the chosen dance genres, social and folk dance, that did not incorporate the opportunity to stand unsupported or stand on one leg for an extended time [22].
As a form of exercise, dance increases health, maintains proper posture, stimulates the muscular system, and improves physical fitness [27].The blend of rhythmic movement, selfexpression, and cultural richness in dancing creates an inherently captivating and appealing experience that resonates with a broader range of individuals.This distinctive quality contributes to the heightened attractiveness of dancing compared to conventional sports activities.Dance positively affects physical function and postural balance, enhancing functional performance crucial for daily activities and improving QoL.Improved QoL through dance training has the potential to promote overall well-being and better health among middle-aged and older adults.After dance class, there is an improvement in subjective well-being and life satisfaction [48].
When engaging in dance therapy or exercise, middle-aged and older adults with varying health conditions may not necessarily prioritize the artistic elements of dance.Instead, dance aims to provide patients with physical and psychological benefits or offer healthy individuals diverse exercise options [45].The participation of older adults in physical activities helps them maintain their physical health and allows them to interact with others.This interaction also removes the sense of loneliness, further stimulating their mental state and enhancing individual well-being [27].Furthermore, dance interventions offer distinct advantages in patient compliance, yielding a lower attrition rate and facilitating long-term engagement.Dance can be inherently enjoyable and engaging, encouraging adherence to the program and minimizing the dropout rate.Additionally, dance's dynamic and social aspects foster a sense of community and camaraderie, further motivating and sustaining engagement in dancing over an extended time.All these combined factors contribute to dance's enduring appeal and effectiveness as a therapeutic intervention.

Strengths and limitations
This comprehensive review delved into the nuanced impact of dance, as compared to the alternative forms of exercise and self-care, on both physical function and QoL among middle-aged and older adults.This systematic review included studies covering physical function (motor, postural control and balance) and QoL.Nonetheless, it is imperative to acknowledge certain limitations encountered in these included studies, especially the participants' baseline health status and the consistency of implementing these interventions.These intricacies warrant careful consideration when interpreting the analyses and results in the current study's systematic review.The integration of dance as an alternative means to traditional exercise programs holds the promise to improve the physical function of middle-aged older adults.This approach can improve overall fitness and elevate QoL among middle-aged older adults.
It should be noted that the quantification of therapeutic outcomes across distinct dance genres needs to be improved.Distinct dance genres inherently encompass diverse dance steps, each with unique movement patterns.For instance, actions like the body's rotation and turn step in dance can stimulate the vestibular system, enhancing balance [12].Similarly, engaging in single-leg standing dance steps can improve gait by increasing leg strength [25].Different diseases and diagnoses also have potential implications for dance interventions.
Consequently, a meticulous approach is imperative when dance plans are personalized, considering the nuanced interplay between these dance movements and the specific manifestations of various diseases.A well-conceived dance regimen must aptly address the disease-specific concerns, ensuring efficacy and safety.Enhancing limb balance may involve a deliberate emphasis on lower extremity-focused movements, encompassing both unilateral and bilateral maneuvers.Such an approach facilitates neuromuscular flexibility within the lower extremities, promoting a comprehensive limb balance.This delicate balance between the specificity of movement and the physiological requirements is paramount in devising a dance plan that maximizes therapeutic outcomes.Additionally, the degree to which various musical elements contributed to the observed effects of these studies remains uncertain.
As for any systematic review, several limitations may arise, including heterogeneity among the study designs, varying dance styles, differences in outcome measures, and potential publication bias.Addressing these limitations, the review aimed to provide a comprehensive and impartial assessment of the current evidence on the effects of dance interventions on physical function and QoL.

Recommendations
There are research areas found in the interpretation of this systematic review that warrant further investigation.First, there is a need to conduct a more in-depth exploration of participants' regular exercise routines to prepare for dance sessions.Understanding the baseline physical activity levels can provide valuable context for interpreting the observed effects of dance interventions.Second, investigating participants' hydration habits is essential, as this can significantly influence physical performance and overall well-being.Moreover, an enhanced examination of participants' awareness of frailty, inability, and longevity could offer valuable insights into the holistic impact of dance interventions.Finally, future studies should include different groups with different diagnoses, as the potential impact of variables such as disease or diagnosis on the results obtained with dance interventions may need to be more accurate.

Conclusions
This review has reported outcomes demonstrating that dance may improve physical function and QoL.These positive results reflect that dance is an effective and safe exercise alternative for middle-aged and older adults.Dance intervention may serve as a potential physical exercise for disease rehabilitation.Also, dancing with music may increase participants' interest and encourage more physical activity among middle-aged and older adults.Further research and exploration are warranted to understand the diverse benefits of dance.

Table 2 .
(Continued) • warm-up: targeting movement speed and size, postural alignment, and other physiological systems required for dance.•dancepart: the reel and hornpipe step.•cold down: flexibility exercises

Table 3
presents measurements of physical function and QoL from the included studies.

Table 3 . Summary of measurement tools in the included studies.
Quality of Life Enjoyment and Satisfaction Questionnaire https://doi.org/10.1371/journal.pone.0301236.t003